Coming up with new solutions

Last week I was honored to present L.D. 683, a bill which will at long last begin really addressing the issue of long term care in Maine. We know Medicaid is a huge driver of our state budget. It is one of the biggest, if not the biggest driver -- and its influence has been growing and will continue to grow as long as this state/federal partnership remains in place. Nationally, one quarter of Medicaid expenditures are for long term care and it may be more in Maine given our demographics and aging population.

Unless we transform the long term care system in Maine -- by setting better priorities in our spending, insuring that dollars are spent on vital quality direct services that people really need rather than excessive and complicated administrative overhead, we will continue to fall further and further behind. In the last legislative session, I proposed very similar legislation. It met with a lukewarm reception from the Department of Health and Human Services management as well as the providers and their advocates who were basically satisfied with their contracts and their role in the system. They did not want to see systems change because they were comfortable. I’ve learned my lesson. This session, I will be looking for a vigorous debate, but will be asking for an up or down vote.

I have literally spent years engaged in this issue and traveling around the country looking at best practices from other states. Some of the best of those ideas are contained in this proposal. These ideas have been successfully implemented in a variety of states -- Minnesota, California, Oregon, Massachusetts -- and I have tried to find the approaches that improved overall quality and also promoted the cost-effective use of taxpayer resources.

Here is the core intent of the bill:

*Break down the silos in service delivery of long term care. We should provide the services Maine people need, when they need it, in the most cost-effective manner and not worry about running programs based on demographics or diagnosis. We should be approaching services from a functional perspective -- making sure people get the services they need to be as independent as possible delivered as cost-efficiently as possible.

*Services should be delivered on a priority basis -- the people with the greatest needs (both medically and financially) should be given the highest priority, so that the limited resources we have to allocate to long term care serve those with the greatest needs. This means better integrating skilled services and support for activities of daily living to enable people to remain at home for as long as possible if that is what they desire.

*We should organize ourselves to best accomplish this goal -- so consolidation of effort is in order. The Department should be organized to manage without creating silos; the provider network should be consolidated to reduce duplication of services or redundant administrative expenses.

*We should reallocate existing dollars away from non-essential administrative overhead and into direct services. That’s not to say that the services are not worthwhile -- they may be. The issue is really this -- Can we afford to spend money on administrative activities when we are facing the budget situation at hand? As good as the extra support services may be -- we need to find the way to direct as much resource as possible into the hands on services that maintain our citizens. Given that, LD 683 would completely redesign our intake system -- expect more work on the front end from AAAs, ADRCs and other intake conduits with the resources allocated from federal sources; eliminate the cumbersome multiple steps in receiving services -- intake, independent medical assessment by Goold, separate service brokerage services by EIM, finally delivery of services from a proliferation of small providers. The process should be much simpler. We need to find out what people need to be independent and then help them make an informed choice about their options -- encouraging use of the most appropriate cost-effective approaches.

*By consolidating program offerings, consolidating the provider network and eliminating expenditures that are not for direct, hands on services we should strengthen the delivery system being able to serve more people, provide higher quality services, pay higher wages to direct care workers, provide more realistic reimbursement to providers, and better utilize tax-payer dollars on the things that really matter.

I want this bill to set a broad direction for the new leadership at the Department to turn its attention proactively to this important part of the health care and support system. Investing state dollars, especially as they leverage federal Medicaid resources can help build an architecture of support for seniors and people with disabilities in all Maine communities. As we build the system and approaches, we should be thinking about all citizens, not just those eligible for direct state supported services. Our MaineCare spending should be a catalyst for systems that work for Maine seniors, people with disabilities and their families.

Unfortunately, this approach makes people uncomfortable because it embraces such significant change. Some of the organizations that have multi-million contracts for services with the state -- many of which have been in place for a decade or more -- may be put at risk in this system realignment. These are the difficult choices that I believe voters asked me to make when you sent me to Augusta to represent you. I look forward to working to fulfill that challenge.